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1 A <br />03/29/2001 15:59 7073745577 <br />01.(25/Ol %VF!,D 13:49 FAX 925 6024720 <br />"!3�i'2k10Fi 15:21 2094583433 <br />WOODWARD DRILLINGS CO <br />I?11C i[NGiNF.FtiING IN(; yip Woodward <br />FIFTH FLOOR <br />PAGE 02 <br />DriIIIn Z 003 <br />PAGE 03 <br />� sen Joaquin County Environrnsrtta! Health Services, Unit IV Waft Permit <br />,< Applic�a�tionmba <br />Supplement <br />JOB ADDRESS: <br />PI=RMiT SRI <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />P:ereby affirm that i em licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br />o` ;he SpsinFss and Professions Code and my licenrsa is In full force and effect. <br />_fi�ense #: rl ciU 791 F-Xpiratlon Date: 7- <br />- 2ZCl ' U 11 ontractor: G.� acs 4� A 2f� � e -i LL I ru C, -,Date: - — , -- — <br />Signature: Title: C�P�✓�•4��o�S ��rfnvri�6 <br />Printed name: _/K X125 ri'Eti�1 <br />WORKERS' COMPENSATION DECLARATION <br />-iereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by 1 <br />See..ion 3700 of the Labor Cone, for the performance of the work for which this permit is issued. I <br />i have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, <br />for the performance of the work for which this permit is Issued. My workers' compensation insurance <br />carrier and policy numbers are: I <br />Carrier: , 1 1A (6 f -l/! <br />Policy Number: 00 0 2?B <br />I certify that in the performance of the work for which this permit is issued, I shall not ©mploy any person in <br />T any manner su as to i7Gcuklitm 4�ut*zGt t.; the warkers' compensation laws of Cd►ifomia, and agree that it i <br />should become subject to the worker's' compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />—Signature: <br />i~ ate: c <br />Printed Name: <br />VVARNINO: FAILURE TO SECURE WORKERS' COMPENSATION COVERArdrz IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENAL11ES AND CiVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />j$1d0,oca.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S Z=EES, AND DAMA1GEs As <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />` .—(signature ofC-5`7 licensed authorized representative), <br />nareby authorise (print <br />r <br />, o tgn thine .g Joaquirr4ounty Welt Permit Application on my behalf. i understand this authorizatlnn is valid <br />mane (f) yomr and is limited to the work plan dated on the front page of this application. <br />!4-17-2000 / MI <br />